1013433937 NPI number — MRS. TESSA CLAIRE BASCO LISW

Table of content: MRS. TESSA CLAIRE BASCO LISW (NPI 1013433937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013433937 NPI number — MRS. TESSA CLAIRE BASCO LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASCO
Provider First Name:
TESSA
Provider Middle Name:
CLAIRE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
TESSA
Provider Other Middle Name:
CLAIRE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013433937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PROVIDENCE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71254-0426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-559-2248
Provider Business Mailing Address Fax Number:
318-559-3381

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SUMMA FAMILY MEDICINE CENTER
Provider Second Line Business Practice Location Address:
55 ARCH ST SUITE 3A
Provider Business Practice Location Address City Name:
AKRON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-375-3584
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I.1700513 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0247305 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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